Citation NR: 9727928
Decision Date: 08/12/97 Archive Date: 08/19/97
DOCKET NO. 95-31 998 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in
Lincoln, Nebraska
THE ISSUES
1. Entitlement to service connection for left knee
disability.
2. Entitlement to service connection for cervical spine
disability.
3. Entitlement to service connection for low back
disability.
REPRESENTATION
Appellant represented by: Disabled American Veterans
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
Harold A. Beach, Counsel
INTRODUCTION
The veteran served on active duty from November 1983
through October 1993.
This matter comes before the Board of Veteransí Appeals
(Board or BVA) as a result of decisions rendered at the
Department of Veterans Affairs (VA) Regional Office (RO)
in Lincoln, Nebraska. In July 1994, the RO denied
entitlement to service connection for the residuals of a
left knee injury and for a history of cervical neck
strain. In September that year, the RO denied
entitlement to service connection for low back pain. The
veteran disagreed with those decisions, and this appeal
ensued.
In April 1997, the veteran had a hearing at the RO before
a traveling member of the Board. The veteran testified
to the effect that his service-connected left knee
disability was due to his service-connected right knee
disability. That claim has not been developed or
certified with the current appeal; and, therefore, it is
referred to the RO for appropriate action.
REMAND
The veteran reports that he was treated in service for
all of the disabilities at issue. The service medical
records contained in the claims file have been provided
by the veteran, however he is not sure that they are
complete (See Report of Contact, VA Form 119, dated in
June 1994.). Although the RO has attempted to obtain
such records through official channels (the last time in
September 1994), including the Naval Personnel Records
Center (NPRC) in St. Louis, Missouri, and the Naval
Reserve Personnel Center (NRPC) in New Orleans,
Louisiana, such attempts have been unsuccessful.
The available service medical records show that in
February 1986, the veteran was seen after falling over an
engine and striking his left lateral distal thigh above
the knee. X-rays were normal, and the diagnosis was soft
tissue injury, left vastus medialis. Thereafter, he was
treated on at least two occasions (July 1987 and May
1989) for left knee problems, variously diagnosed as mild
traumatic effusion following exercise and left knee
strain.
Since service, the veteranís left knee has been examined
by VA on multiple occasions. The relevant diagnoses were
knee pain by history (January 1995) and arthralgia, upper
and lower extremities, mild (December 1996). The
examiners did not render an opinion as to whether any
left knee disorder was related to service.
The available service medical records also show that
starting in March 1987, the veteran was treated on
several occasions for complaints of cervical spine pain,
primarily diagnosed as cervical strain. During the
several VA examinations performed since his discharge
from service, the relevant diagnosis was history of
cervical neck strain, negative examination (January
1994).
Finally, the available service medical records show that
starting in October 1985, the veteran was seen on
numerous occasions for complaints of low back pain. The
various diagnoses included lumbar paraspinous muscular
strain, greater on the left than the right; lumbar
sprain; mild thoracolumbar strain with somatic
dysfunction; scoliosis with spasms associated with pain
and obesity; and a functional level of low back pain. In
April 1993, the veteran was involved in a motor vehicle
accident which reportedly caused mild lumbar strain with
spasms. On the report of medical history associated with
his September 1993 service separation examination, it was
noted that he had had recurrent low back, status post
motor vehicle accident in April 1993 and excess weight.
During the several VA examinations performed since the
veteranís discharge from service, the relevant diagnosis
was thoracic and lumbar back pain with no bony
abnormalities noted (August 1994). The examiner stated
that there was no evidence of neurologic impairment and
that the veteranís back problems were most likely
muscular in origin.
During his hearing on appeal, the veteran testified to
the effect that since service, he had received treatment
for his left knee and cervical and lumbar spine at the VA
Medical Center (MC) in Lincoln, Nebraska. Those records
are not on file; however, they could well be relevant to
the veteranís claim.
Inasmuch as there may be outstanding evidence in this
case and inasmuch as various diagnoses have been rendered
for each disability at issue, the Board agrees with the
veteranís representative that additional development of
the record is necessary prior to further appellate
consideration. Accordingly, the case is remanded for the
following actions:
1. The RO should contact the veteran
and request the names, addresses, and
dates of treatment or examination, of
all health care providers who have
treated or examined him since
December 1996 for left knee
disability, cervical spine
disability, and/or low back
disability. After obtaining any
necessary authorization, the RO
should request copies of the records
of such treatment or examinations
directly from the providers. This
should include, but is not limited
to, records of treatment reportedly
rendered at the VAMC in Lincoln,
Nebraska. The RO should also request
that the veteran provide any such
records in his possession. Any
records so obtained must be
associated with the claims folder.
Failures to respond or negative
replies to any request should be
noted in writing and also associated
with the claims folder.
2. When the foregoing actions are
completed, the RO should schedule the
veteran for an examination by an
orthopedist. The purpose of the
examination is to determine the
nature, etiology, and extent of any
chronic identifiable musculoskeletal
disability of the left knee, cervical
spine, and/or low back disorder found
to be present. All indicated tests
and studies should be performed, and
any indicated consultations should be
scheduled. Prior to the examination,
the claims folder must be made
available to the examiner so that the
relevant medical history may be
reviewed. Should any chronic
identifiable musculoskeletal
disability of the left knee, cervical
spine, and/or low back be found, the
examiner should render an opinion as
to whether they are at least as
likely as not related to the various
musculoskeletal problems recorded in
service. Such opinions should be
supported by clear and complete
rationale.
3. When the requested development
has been completed, the RO should
readjudicate the claims of
entitlement to service connection for
left knee, cervical spine, and low
back disability. If the benefits
sought on appeal are not granted to
the veteranís satisfaction, he and
his representative must be furnished
a Supplemental Statement of the Case
on all issues remaining in appellate
status and afforded an opportunity to
respond. Thereafter, if otherwise in
order, the case should be returned to
the Board for further appellate
action.
By this remand, the Board intimates no opinion as to the
final disposition of any issue. The purposes of the
remand are to develop the evidence and to ensure
compliance with due process of law. The veteran need
take no action until he is notified.
WAYNE M. BRAEUER
Member, Board of Veterans' Appeals
38 U.S.C.A. ß 7102 (West Supp. 1996) permits a
proceeding instituted before the Board to be assigned to
an individual member of the Board for a determination.
This proceeding has been assigned to an individual member
of the Board.
Under 38 U.S.C.A. ß 7252 (West 1991), only a decision of
the Board of Veterans' Appeals is appealable to the
United States Court of Veterans Appeals. This remand is
in the nature of a preliminary order and does not
constitute a decision of the Board on the merits of your
appeal. 38 C.F.R. ß 20.1100(b) (1996).
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